Job responsibilities
Main tasks/overview of
responsibilities:
There may be, on
occasion, a requirement to carry out other tasks; this will be dependent upon
factors such as workload and staffing levels.
The Care Coordinator
will undertake work in line with PCN directed priorities, work within their
scope of practice and:
Act
as a point of contact between GP, patients and carers and other agencies.
Liaise
with GPs and practice teams to identify patients who are elderly, frail or who
have long term health needs and support.
Act
as the first port of call for care homes and MDT.
Ensure regular and consistent communication with
care homes regarding patient progress and any complications.
Liaise with
primary, secondary and specialist care services as required.
Work with
the multi-disciplinary team to help identify people at risk of loss of independence
or admission to hospital as a result of inadequate social support.
Provide
these cohorts of people signposting to identified services in order to maintain
their independence and improve their health and well being.
Visit
patients in community, home or care home settings to assess and discuss their
care needs involving carers as appropriate.
Assist with
personal care plans for individual patients, ensuring preventative actions are detailed
to support the appropriate use of services.
Communicate
the care plan to the GP and any other professionals involved in the persons care
and upload to the relevant records.
Ensure that
identified patients receive the right level of help at the right time and help
them to experience a joined up service by liaising with relevant Organisations.
Work with
patient, carers and healthcare team members to encourage the patient to adopt effective
self-management and self-help seeking approaches to reduce unnecessary Hospital
admissions.
Liaise with other
agencies to ensure timely and appropriate engagement as required.
Support
patients to access community care assessments as well as carers assessments.
Where a
personal healthcare budget is allocated provide advice as required regarding
the key choices the patient will need to make.
Identify
unpaid carers and direct them to access services as appropriate to provide them
with support.
Identify
when urgent action or a step up in care is required and promptly alert the
relevant professionals involved, highlighting any safety concerns.
Follow up on
communications from out of hospital and in-patient services regarding changes in
condition of patients to support the practice to respond proactively to
potentially unmet needs.
Undertake
visits or telephone contact to manage patients on the PCNs case load following
any unplanned hospital admissions where appropriate.
Participate in MDT meetings to discuss patients
actively being managed by the CHAT Team and any other patients from the PCNs
case load needing discussion.
To attend
CHAT Team MDT meetings plus any other meetings where there is a need to discuss
patients on case load. Updates between meetings to be shared with the Liaison
Officer on behalf of the Practices.
Undertake
visits or arrange appointments at their Practice for patients on the PCNs case
load or otherwise as directed by the Duty Doctor following identification of
urgent and non-urgent clinical need to assess, diagnose, treat, prescribe and
refer appropriately according to the patients health needs and acting within
the PCNs clinical skill set.
Maintain accurate and up to date records of
patient contacts using GP record systems and other IM&T systems relevant to
the role i.e. entering notes onto EMIS using agreed read codes.
To run regular patient searches using EMIS in
order to have an up to date record of progress of achievement of Key
Performance Indicators.
Work with Shelton & Hanley Neighbourhood
teams and other agencies to support and further develop this role.
Support the
PCN in providing KPI reports for submission as requested.
Monitor
patients to ensure tasks are completed and care delivered.
All employees should understand it is their
personal responsibility to comply with all organisational and statutory
requirements (e.g. health and safety, equality and diversity, confidentiality
and clinical governance). All roles will
require flexible working to contribute to extended hours services.
Additional Information
The post holder will be expected to
deliver a high quality, diverse, patient centred service.
Full training will be given in all
aspects of the job where necessary.
You will be expected to attend regular
Network and staff meetings. The meetings provide an opportunity to discuss matters arising
from the job and can be used for in-house training.
Communication
The post-holder should recognize the importance of effective
communication within the team and will strive to:
Communicate
effectively with other team members.
Communicate
effectively with patients and carers.
Recognise
peoples needs for alternative methods of communication and respond
accordingly.
Information
Governance
Information is vitally important
for the safe clinical management of patient care and the efficient administration
of services. It is the responsibility of our entire workforce, regardless of employment
status, to ensure they abide by the requirements of Information Governance as
set out in the Employee Handbook and the Information Governance Policy.
Confidentiality
In the performance of the
duties outlined in this Job Description, the post-holder may have access to
confidential information relating to patients and their carers, Network staff
and other healthcare workers. They may also have access to information relating
to the Network as a business Organisation. All such information from any source
is to be regarded as strictly confidential.
Information relating to
patients, carers, colleagues, other healthcare workers or the business of the
Practice may only be divulged to authorised persons in accordance with the
Network policies and procedures relating to confidentiality and the protection
of personal and sensitive data.
Rehabilitation
of Offenders Act 1974
This post is not exempt
from the provisions of the Rehabilitation of Offenders Act 1974. Therefore the
post holder is required to disclose any spent convictions.
Health
and Safety
It is the responsibility
of the individual to work in compliance with all current Health and Safety legislation
and the Practice Health and Safety Policy. To attend any training requirements,
both statutory and mandatory, in line with the legal responsibility to comply
with the Health and Safety at Work Act 1974.
Other
Requirements
This Job Description is
not an exhaustive list and will be reviewed in the light of changed needs and
Organisation development. Any changes will be discussed with the post holder
who will be required to carry out other duties appropriate to the grade and
scope of the post. The post will involve regular travel locally and, on
occasion the post holder may be required to undertake occasional evening or
weekend work.
